Part Two
- Patient complaints and suggestions policy
Patient complaints and suggestions policy
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Politics:
The hospital is committed to establishing a system or procedure to ensure that patients know how to submit their complaints and suggestions, to work on examining and eliminating the causes of complaints, and to study the suggestions submitted by patients and their families.
The Purpose:
Clarifying how patients and their families can submit a complaint or suggestion, ensuring that the complaint is examined, its causes removed, and the proposals submitted to continue the hospital’s performance improvement process.
Methods for submitting complaints and suggestions:-
- First: Complaints received from outside the hospital.
- Second: Complaints issued from within the hospital.
Procedures:
First: Complaints received from outside the hospital.
1. The secretarial employee receives complaints received by the hospital from abroad by phone and reports them to the Citizens Service Office.
2. The secretarial employee directs the complainant to the Citizens Service Office.
3. The Chairman of the Complaints Committee reviews the complaint and identifies the department or persons responsible to verify and respond to it.
4. The person responsible (Citizens Service) for verifying the complaint writes an appropriate response to present to the Chairman of the Complaints Committee.
5. The Chairman of the Complaints Committee determines the necessary action to be taken regarding the complaint.
6. The Chairman of the Complaints Committee determines who will send the response to the party concerned with the complaint or contact the complainant by telephone/telegraph to set an appointment to meet him and inform him of what has been taken regarding the complaint.
Second: Complaints issued from within the hospital.
1 - Complaints submitted through complaint boxes:
The hospital administration sets up boxes to collect complaints from customers by distributing them in different areas of the hospital (administration building - reception).
· The Complaints Committee opens complaint boxes, classifies them, and delivers them to the Chairman of the Committee.
· The Chairman of the Complaints Committee examines the complaint and writes a summary of it in the event that the name of its submitter is not mentioned to present it to the director to discuss what was reported in it. In the event that the name of its submitter is mentioned, the Chairman of the Committee assigns someone to respond to what was stated in the complaint.
The results of complaints are submitted to the manager on a weekly basis.
· The hospital director takes the necessary action according to the result received.
2- Complaints submitted by telephone:
· The patient or his representative calls the extension number announced at the hospital.
· The Director’s Secretariat will listen to the complaint and record it in the relevant register, provided that at the end of the working day it informs the Chairman of the Complaints Committee of all complaints in the register.
· Complaints are received by telephone during morning working hours (8:00 a.m. to 2:00 p.m.)
3- Receiving patients’ complaints during personal interviews with them:
First: The patient or his representative submits a complaint:
The patient or his representative submits his complaint to the citizen service official.
· Second: Citizen Service Office employee passing through the internal departments:-
v Complaints Committee to discuss the problems and what has been done regarding them.
Third: Passing by the Patient Rights Coordinator:
v The citizen service office employee visits patients, listens to their complaints, records them in the special form, and works to resolve them by contacting the official. In the event of inability to do so, he submits them to the head of the complaints committee.
· The Citizen Service Office employee presents the complaint form daily to the supervisor
1. The Patient Rights Coordinator visits a random sample of patients to hear their complaints and suggestions, ensures that the Citizen Service Office employee visits them, and records those complaints, if any, in his visit record.
2. The citizen service official examines the complaints he finds.
3. The Citizen Service Officer fills out the patient satisfaction form in the section relevant to the complaint if the complaint or proposal needs follow-up.
Actions taken with complaints
· The Chairman of the Complaints Committee addresses the departments relevant to the complaint or proposal, either orally or in writing.
· The department concerned with the problem or proposal is committed to researching it and responding to it within a specific period of time determined by the committee chairman.
· Upon the expiration of the specified period of time, if an appropriate decision has not been taken in the relevant department, the matter shall be presented to the director for a decision to be made with the hospital administration.
· The hospital director’s recommendations for a solution are followed up by the citizen service official and the complainant is informed of the outcome.
· The confidentiality of the person reporting the complaint is maintained without attacking him or attempting to harm him.
Administrator:
- Director’s secretarial officer.
- Complaints Committee.
- Citizen Service Officer
Models:
- Patient Complaints Passing Form
- Inpatient complaint form.
- Patient opinion survey form.
Documentation:
- Complaints register.
The Reviewer:
Egyptian accreditation standards from 2013.
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Policy for obtaining informed written consent
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Politics:
The hospital follows a policy of obtaining patient consent in accordance with regulations and laws.
The Purpose:
Preserving the patient’s rights and obtaining the patient’s consent before providing health services to him in accordance with regulations and laws.
A - The patient’s attendance at the hospital is considered implicit consent to conduct medical examination and treatment in accordance with the text of Article No. 28 of the Regulations on Ethics and Honor of the Human Medicine Profession issued by Minister of Health and Population Resolution No. 238 of 2003.
B - The patient or whoever has the legal right to sign must sign the general declaration of consent to enter the hospital and receive treatment when the patient enters the hospital (general declaration form for hospital admission).
C - Physicians and hospital nursing staff must obtain informed written consent from the patient or his legal representative in all of the following cases (except for life-saving reasons):
- Surgical intervention.
- Hemodialysis.
- General anesthesia, sedation, or deep sleep.
- Transfusion of blood and blood products.
- Surgical and diagnostic endoscopy
Action Steps:
1. The acknowledgment of approval for the therapeutic procedure is deposited in the relevant section of the patient’s file after the signature of the patient or whoever has the legal right to do so.
2. The treating physician explains the reasons, advantages and risks of the procedure to be performed, along with explaining the consequences and alternatives resulting from it to the patient or whoever has the legal right to do so.
3. Doctors are obligated not to carry out this procedure before confirming the existence of the declaration signed by the patient or who has the legal right to do so.
4. The doctor must commit to explaining the procedure and its details, mentioning (the reasons - advantages - risks) to the patient or his family.
5. The patient, or whoever has the legal right to do so, signs the aforementioned declaration and records the date and time of signing.
6. The surgeon and anesthesiologist sign their commitment to the procedure mentioned in the declaration.
7. Determine the validity period for the approval of the therapeutic procedure to be thirty days from the date of the patient’s signature or whoever has the right to do so legally. If the patient’s condition requires emergency circumstances or based on the instructions of the treating physician based on the patient’s condition follow-up forms, the implementation of another procedure in addition to the first procedure or To change the type of procedure, a new approval must be obtained from the patient or whoever has the legal right to do so.
8. The declaration required to be signed by the patient must contain:-
- Patient name
- Name of the process/procedure.
- Type of planned anesthesia.
- Name/signature of the anesthesiologist.
- Name/signature of the surgeon.
- The date of the declaration must be prior to the date of the transaction.
- Signature of the patient/guardian/guardian
9. In the event that the patient is unable or qualified to sign the declaration (a minor, incapacitated person, or unconscious person), the following order shall be followed, with documents proving this to be submitted:
- The guardian, guardian, or guardian by law (provided that he submits proof of this).
- Husband/wife.
- One of the parents.
- One of the adult children.
- A grandparent or adult grandchild.
- An adult third-degree relative, provided that the degree of kinship is proven
10. In the event that the patient is unable to read and write or is unable to understand the information explained by the doctor, the patient’s fingerprint or stamp must be taken on the declaration, provided that one of the relatives indicated in the previous clause signs as a witness to the consent declaration and proves this before the doctor.
Due to the nature of the hospital’s work and the frequency of dealing with serious and critical cases, the approval must include permission for the transfusion of blood and its derivatives.
11. In cases of loss of consciousness and critical cases that affect the patient’s life, the medical team can perform some surgical interventions to save the patient’s life before obtaining the patient’s consent or it is not possible to obtain consent from his family, provided that the hospital director or his representative forms a committee of the treating physician, another physician, and a physician. anesthesia by signing that the procedure to be performed is life-saving and the reasons for its speedy procedure before obtaining the declaration referred to in the previous clause.
Administrator:
- Physician.
- Responsible department nursing staff members.
- The hospital director or his representative (department head - shift consultant - hospital alternate director - administrative deputy - head of the medical staff)
Models:
- Consent acknowledgment form
The Reviewer:
- Professional Ethics Regulations No. 238 of 2003.
- Ministerial recommendations to maintain patient safety during anesthesia.
- Egyptian Accreditation Standards 2013.
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The policy of informing the patient of the outcome and expected costs
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Politics:
- The medical service provider’s commitment to informing patients and their families of the results of the treatment and medical care provided to them and the expected costs.
The Purpose:
- Creating a system to inform patients and their families of the outcome of the medical care or treatment provided to them and the expected costs.
Procedures:
1. Doctors and medical service providers who have the right to evaluate the patient perform the required examinations and analyses.
2. The patient’s diagnosis is verified by the treating physicians or other groups.
3. Doctors develop the treatment or care plan required for the patient.
4. Doctors and medical service providers inform the patient of the treatment plan, alternative plans, complications and side effects, if any, and the expected result of each plan.
5. According to Article 21 of the Professional Ethics Regulations, it is permissible for humanitarian reasons not to inform the patient of the serious consequences of the disease. In this case, he must inform the patient’s family in a humane and appropriate manner of the seriousness of the disease and its serious consequences unless the patient expresses his desire not to inform anyone about his condition or specifies Certain people to inform them of it without risk to those around him.
6. Doctors and medical service providers inform the patient and his family of the expected costs of service and treatment. (See PR.2.10)
Administrator:
- Physician.
The Reviewer:
- Clinical evidence.
- Regulations of professional ethics.
- Egyptian quality standards approved from 2013.
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Patient property preservation policy
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The hospital administration is committed to preserving patients’ belongings and working to encourage patients to send all their belongings to their homes or friends.
- Determine the hospital department and its responsibilities for patients’ property.
- The patient’s possessions (money, jewelry, watch, check book, wallet, etc.) are examined, recorded, and kept as safe deposit boxes in the hospital in the event that the patient’s identity is unknown or unconscious.
The Purpose:
- Preserving the patient’s property and specifying the hospital department to preserve it to ensure that the hospital is not exposed to accountability.
Working procedures:
· Patients should not keep any private property during their stay in the hospital.
· The patient, or whoever is legally entitled to do so, signs a declaration stating that he does not have any property if he does not have any property with him.
In the case of an unidentified patient (inability to determine the patient’s identity):
1. The responsible employee (hospital assistant) collects the patient’s belongings in a folder in the presence of the emergency nursing supervisor.
2. The assistant writes the contents of the portfolio (if the property is jewelry that is not described as gold or silver, but rather as a yellow ring with a white bezel, or silver jewelry... etc.) on the patient’s safe list form.
3. The person in charge of the emergency safe deposits, along with the nursing supervisor in charge of the emergency or her representative, sign the contents of the safe deposit list.
4. The person in charge of emergency safekeeping writes the patient’s name, date, and patient entry permit information on the clipboard in which the patient’s belongings are kept.
5. The person in charge of emergency safe deposits records the patient’s data in the relevant safe deposit register and places the number for the patient’s safe deposit list in the designated place in the safe deposit register.
6. The person in charge of emergency safe deposit boxes shall keep and secure the wallet in a designated safe deposit box and keep it tightly closed until requested by the patient himself or by someone who has the legal right to do so upon request.
7. The contents of the wallet are delivered to the patient according to the list available when he requests it, with his signature of receipt and his fingerprint being taken in the secretariat register.
· When the patient is discharged from the hospital.
1. The nursing staff supervising the patient’s treatment will notify the person in charge of safekeeping to bring the portfolio after ensuring that the numbers and contents match the receipt list available with the patient or whoever is legally entitled to receive it.
2. The employee responsible for safekeeping opens the wallet in front of the patient or whoever is legally entitled to do so, and the contents in the wallet are counted separately (money, jewelry, etc.).
3. The patient, or whoever is legally entitled to do so, retrieves the entire contents of the wallet and signs this in the safe deposit register, recording the date and hour of the retrieval, and the responsible employee signs as a witness to this.
4. A copy of the patient’s safe list is placed in his file.
Determine the hospital department and its responsibilities for patient property
The employee responsible for the deposits informs the patient or his legal representative that the hospital is considered responsible for the property of the unconscious patient only upon his arrival and the official receives the patient’s deposits, registers them, and signs their receipt, until the patient or his legal representative hands over the deposits and signs their receipt.
Administrator:
- Hospital Assistant.
- Responsible department nursing staff members.
Models:
- Declaration of the absence of property.
The Reviewer:
- Egyptian Accreditation Standards 2013.
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